Study Objectives:

•To outline the Kalmunai Model of mental health care.•To better understand the factors of this models success.•To inform policy makers and clinicians working in low resource, geographically dispersed catchment areas about successful, low cost methods of service delivery and mental health care.

• MH Unit of the Kalmunai Base Hospital, bi-weekly clinics.

• 14 bed-in patient clinic, where first episode patients stay for initial treatment and assessment period.

• Larger psychiatric rehabilitation Centre when more chronic patients.

• 13 Satellite Clinics located throughout the catchment area that staff visit once a month.

• 14 Psychiatric Social Assistants (PSAs) who work with mental health staff to recruit new patients, follow patients, administer psychiatric care in rural communities.

• Trains and empowers families to act as co-therapists.

William Affleck, PhD (Candidate)1,2 M.R.M. Hameem, PSW,2,3 P. Judy Ramesh Jeyakumar MBBS, D.Psy, FMH4 1 PhD (Candidate), Department of Psychiatry, Faculty of Medicine, McGill University, Montreal, Canada; 2 Mental Health Unit, Kalmunai Base Hospital, Kalmunai, Sri Lanka ; 3 Mental Health Services, Valachchanii,

Batticaloa, Sri Lanka 4Kalmunai Mental Health Association, Kalmunai, Sri Lanka. Contact Address: william.affleck@gmail.com

• MH Unit Kalmunai, with the help fo PSA’s and community volunteers, organize educational meetings and awareness raising activities in rural communities.

• Mental Health Month- Street marches, awareness raising events in towns and villages.

• Works with a variety of community organizations to increase the visibility of mental illness.

• Conducts a number of outreach campaigns to increase awareness of mental health and referral systems. This includes working with the local media, distributing pamphlets, and conducting educational campaigns at the local schools.

• Creates an environment for the public to visit and interact with the patients at the hospital and psychiatric rehabilitation Centre

From the Bottom Up: Understanding the Kalmunai Model of Community Psychiatry in Eastern Sri Lanka

• Initial treatment in the hospital to control the the illness through medication, modifying the patients problematic behavior.

• Training of families to cope with mentally ill family member at home.

• Encouraging families to visit the hospital, family quarters with bedroom, cooking facilities, etc.

• Empowering the patient to earn income to contribute to the day to day expenses of the family.

• Build a network of families who are coping with mental illness to increase social support.

• Undertake efforts to raise awareness and decrease stigma surrounding mental illness in order to decrease family’s shame and social isolation from their community.

Discussion:

The strength of the Kalmunai Model lies in the combination of its unique service delivery model and its holistic approach to treatment. By making use of pre-established community support systems such as volunteers, lay professionals, and PSAs, which were formerly community officers of health, this model is able to deliver effective mental health care to even the furthest most rural areas of the catchment area, at a fraction of the cost of traditional mental health care.

Unlike other models, which focus on individual, the Kalmunai model recognizes the healing of mental health takes place at the level of relationships. By working holistically with the patient, their family and their community, the Kalmunai Model addresses the social determinants of mental health, and does not solely focus on controlling the symptoms and behaviors of the patient alone. Due to the vague and subjective nature of recovery, it can be difficult to determine the efficacy of mental health services. However, there are many external indicators that point to the Kalmunai Models’s success. This includes a very low (20%) rate of patient re-admittance, and a 97% successful repayment rate of microloans given to mental patients and their families. There are also number of anecdotal indicators of success. For example, the rate of admissions after first episode psychosis has increased dramatically, where as before individuals and families would spend a considerable amount of time and money consulting and working with traditional healers. This change demonstrates that the various public awareness efforts are having a positive effect. Similarly, a higher number of patients in the acute ward of the Kalmunai Base Hospital are choosing to remain in the unit, whereas before a high number opted to leave the hospital against the clinician’s recommendations. This suggests that the anti-stigma campaigns and efforts to make the patients feel welcome and happy are working. While these indicators may not be enough to make a full evaluation, they do suggest that the Kalmunai Model is achieving measurable success.

Introduction: There are numerous

interrelated challenges that clinicians and policy makers face in delivering mental health care to low and middle income countries, including logistical challenges, social challenges, familial challenges, and challenges with individual patients.

A community psychiatry program operating on the east coast of Sri Lanka known as the “Kalmunai Model” has found innovative ways of not only navigating these barriers, but also providing higher quality mental health care than traditional models.

Individual Challenges

IllnessLack of self-esteemLack of self-awarenessLack of life skills and employabilityLack of social/family supportSocial isolation.

Family Challenges

Lack of knowledge and/or financial resources to cope with the patient.Because of stigma there is often high levels of shame, and families do not have adequate amount of support from their community.Family cohesion suffers due to an individual(s) mental illness.

Social Challenges

Low amount of awareness of mental health and mental health literacy lead to many mentally ill people going unreported, or blamed for their illness.High stigma results in discrimination of patient and their family, can lead to families hiding their mentally ill members.

Logistical challenges

Geographically large catchment areas and poverty make it difficult or impossible for rural population to reach hospitals in city centers.Lack of priority and funding for mental health services, and high levels of mentally ill make it difficult to meet the health needs of the population.

• Control illness through medication and number of psychosocial treatments.

• Educate the patient about their illness, symptoms, common difficulties, etc.

• Increase the patients self-esteem through job training, life skills training, community employment and locally appropriate microfinance opportunities.

• Give the patient a sense of community and social connection by keeping them in the family.

• If unable to return to the family, create a family environment at the hospital/ rehabilitation Centre so that the patient can feel comfortable and at home.

• Work with government when needed to provide housing, money, and basic necessities to chronic patients (Help for Patients with Disabilities Fund).